CASE REPORT

BRACHIAL PLEXUS INJURY POST

GANGLIONIC C5-C6
 IDENTITY

Time of the examination : November, 2017

Name : Mr. EK
Gender : Male
Age : 62 years old
Religion : Islam
Status : Married
Occupation : Builder
Referral Diagnosis : Left brachial plexus
injury post ganglionic C5-6 complete lesion at
level root
 ANAMNESIS
Chief Complaint :
Weakness at left arm
 ANAMNESIS
Present Illness:
The weakness was felt since 5 years ago after the
patient had work accident. When he brought the
wooden block, the patients hand was attracted.
The activity of lifting arm and bending the elbow was
difficult.
The symptom worsened in the last 1 year.
Tingling (+), pain at left shoulder (NRS 1-2), numbness
(+)
All ADL independent except when dressing (buttoning
clothes)
 ANAMNESIS
History of past illness: CAD post PCI 1 year ago,
regularly consumed clopidogrel, acetosal,
bisoprolol,simvastatin and B complex supplement.
History of Functional Ability :
His functional ability is normal before sick
Psychosocialeconomy Status:
the patient worked as a builder, but retired since the
symptom was worsening (last 1 year)
His wife is his care giver, he live together with his wife
and children.
His income from his children
 PHYSICAL EXAMINATION
I. General Status
Consciousness : Compos mentis
Vital Sign
- Blood Pressure : 120/80 mmHg
- Heart Rate : 60 x/m, reguler
- Respiration Rate : 18 x/m
- SpO2 : 96 %
- Temperature : 36,5 0C
 PHYSICAL EXAMINATION
Head : CA -/-, SI -/-, pupil isokor 3 cm, RC +/+
Neck : JVP normal
Thorax : shape and movement symetric
- Cor : normal heart sound, murmur
- Pulmo : VBS right=left, Slem -/-, Ronchi -/-,
Wheezing -/-
Abdomen : flat, supple, normal bowel sound
Hepar and Spleen are not palpable
Extremities : Cyanosis (-), CRT <2 seconds
 PHYSICAL EXAMINATION
Motoric
- a/r Head and Neck :
ROM full
Motoric 5
- a/r Trunk
Alignment : normal
- a/r Upper Extremities
Deformity : Left Shoulder subluxation 2 cm
Atrophy of Left Rotator Cuff Muscles and Deltoid
ROM full
Muscles :
Trapezius m 5/5
Rhomboid m 5/1
Serratus anterior m 5/1
 PHYSICAL EXAMINATION
Pectoralis mayor m 5/1
Supraspinatus m 5/1
Infraspinatus 5/2
Lattisimus dorsi 5/1
Teres mayor 5/1
Deltoid m 5/1
Biceps m 5/2
Brachialis m 5/1
Triceps m 5/1
Brachioradialis m 5/2
Extensor carpi radialis longus 5/5
Supinator m 5/4
Extensor carpi ulnaris 5/5
Extensor digitorum 5/5
 PHYSICAL EXAMINATION
Abductor pollicis longus 5/5
Extensor pollicis longus 5/5
Extensor policis brevis 5/5
Extensor indicis 5/5
Pronator teres 5/4
Flexor carpi radialis 5/4
Flexor digitorum superficialis 5/5
Abductor policis brevis 5/5
Flexor policis brevis 5/5
Lumbrical 5/5
Pronator quadratus 5/5
 PHYSICAL EXAMINATION
Flexor digitorum profundus 5/5
Flexor policis longus 5/5
Flexor carpi ulnaris 5/5
Hypothenar muscles 5/5
Abductor policis 5/5
Flexor policis brevis 5/5
Palmar interossei 5/5
 PHYSICAL EXAMINATION
Diameter upper arm 26/25 (3 inchi upper from
lateral condyle)
Diameter lower arm 25/25 (3 inchi under lateral
condyle)
 PHYSICAL EXAMINATION
a/r lower extremities
ROM full
Motoric : All 5
 PHYSICAL EXAMINATION
Reflex :
Physiologic Reflex: BTR : ++/++
APR : ++/++
KPR : ++/++
Pathologic Reflex : -
 PHYSICAL EXAMINATION
Sensory Examination
C5 normal/decrease 50%
C6 normal/decrease 50%
C7 normal/normal
C8 normal/normal
T1 normal/normal
Bowel and bladder:
Normal
 PHYSICAL EXAMINATION

III. Functional Status

Communication : - expresif good
- receptif good
Feeding : good
Mobilization : all dependent
 PHYSICAL EXAMINATION
Communication : normal
Hand Prehension : Power grip : good/impaired
Cylindrical : good/good
Spherical : good/good
Hook : impaired/good
Tip to tip : good/good
Tip to lateral : good/good
Pinch : good
Reaching : good/impaired
 PHYSICAL EXAMINATION
Balance :
Sitting
Static and dinamic :
Standing
Static and dinamic :
SUPPORTING EXAMINATION
 EMG
NCS examination : axonal sensory lession at
left radialis nerve, motoric axonal lession at
left radialis nerve, bilateral ulnar nerve.
EMG examination : appearance of fibrilation
(+), PSW (+), POLIPHASIC (+), CRDS (+), MUAP
decrease at left brachial plexus post ganglionic
suitable with corda posterior and inferior. This
is supporting the diagnose of right plexus
brachialis posterior inferior
 MEDICAL DIAGNOSIS
Medical Diagnosis :
Plexus brachial injury post ganglionic C5-6

Comorbid Medical Diagnosis : -

 Rehabilitation Diagnosis
Impairment : Brachial plexus injury
Disability : ADL disturbance
Handicap : Vocational
 PROBLEM LIST
Medical Problem Rehabilitation Problem

- Brachial plexus injury - ADL

- muscle atrophy
- subluxation
- Weakness
 REHABILITATION PROBLEM REVIEW AND MANAGEMENT
Problem : ADL
Cause : brachial plexus injury
Limitation : shoulder subluxation, muscle weakness
Potency : Caregiver (wife and son), Good motivation
Prognosis : Independent ADL
Target : Dressing Independently
Preventing worsening shoulder subluxation
Muscle mass mantained
Program : 1. OT : ADL (dressing) exercise/modification
2. flexibility exercise shoulder and elbow sinistra
F: every day, 3x/day,
i : 10 rep, 3 set
T : pasif ROM shoulder, elbow sinistra to all direction
2. ES a/r rotator cuff muscles and deltoid muscle
F: 2X/week
3. muscle strengthening exercise : trapezius and flexor group muscle elbow and wrist sinistra
F : 2X/week
I: 75% from IRM
T : isotonic strengthening exercise trapezius muscle sinistra, elbow flexor sinistra, wrist flexor
sinistra
Time : 12 minggu
4. orthosis : shoulder sling sinistra
5. education :
- Wearing shoulder sling sinistra, positioning of shoulder sinistra
- flexibilty exercise such as the exercise above
- muscle strengthening exercise trapezius and flexor group muscle like the prescription above 3
times a week
THANK YOU